title: Operative strategy modifies risk of pouch-related outcomes in patients with ulcerative colitis on preoperative anti-tumor necrosis factor-α therapy.
abstract: BACKGROUND
  Whether preoperative biological therapy increases postoperative complications after restorative proctocolectomy remains controversial.
  
  
  OBJECTIVE
  This study aims to evaluate the influence of preoperative use of biologics on outcomes after restorative proctocolectomy and to assess whether a staged approach modifies any negative influence of these medications.
  
  
  METHODS
  The study was conducted at a single tertiary institution.
  
  
  METHODS
  Patients who were operated on for medically refractory ulcerative or indeterminate colitis were identified and classified by initial surgery, whether subtotal colectomy or total proctocolectomy, then categorized into biologics user and nonuser groups. Demographics, perioperative data, postoperative complications, pouch function, and quality of life were collected.
  
  
  METHODS
  Cumulative 1-year complication rates were estimated by using the Kaplan-Meier curve, and independent predictors for infectious complications were identified by using Cox proportional hazards regression models.
  
  
  RESULTS
  From 2006 to 2010, 407 and 181 patients underwent initial subtotal colectomy with end ileostomy or total proctocolectomy with IPAA. For the 181 patients who underwent total proctocolectomy straightaway, pre- and perioperative data were comparable for biologics users (n = 25) and nonusers (n = 156). Cumulative 1-year pelvic sepsis rate was significantly greater in patients on biologics (32% vs 16%, p = 0.012). Multivariate analysis demonstrated that preoperative anti-tumor necrosis factor therapy (HR, 2.62; p = 0.027) was an independent risk factor for postoperative pelvic sepsis after total proctocolectomy. After subtotal colectomy, no differences occurred in both 30-day and cumulative 1-year postoperative complications between biologics users (n = 142) and nonusers (n = 265). Outcomes were also similar when biologics users (n = 88) and nonusers (n = 164) underwent subsequent completion proctectomy with ileal pouch creation after initial colectomy.
  
  
  CONCLUSIONS
  The retrospective nature of this study and physician's preference were limitations.
  
  
  CONCLUSIONS
  Preoperative exposure to biologics is associated with an increased risk of pelvic sepsis after total proctocolectomy with IPAA. This risk is mitigated by the performance of an initial subtotal colectomy.
authors.affiliation: 1 Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 2 Department of Gastroenterology/Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jinyu
authors.initials: J
authors.lastname: Gu
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
authors.forename: Bo
authors.initials: B
authors.lastname: Shen
authors.forename: Jon D
authors.initials: JD
authors.lastname: Vogel
authors.forename: Ravi P
authors.initials: RP
authors.lastname: Kiran
mesh_terms: D000068879:Adalimumab; D000293:Adolescent; D000328:Adult; D000368:Aged; D000911:Antibodies, Monoclonal / Q000008:administration & dosage / Q000009:adverse effects*; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000009:adverse effects*; D003093:Colitis, Ulcerative / Q000601:surgery; D005260:Female; D005765:Gastrointestinal Agents / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D007081:Ileostomy; D000069285:Infliximab; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016737:Proctocolectomy, Restorative / Q000009:adverse effects* / Q000379:methods; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000453:epidemiology*; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D055815:Young Adult
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D005765:Gastrointestinal Agents; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab